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Refining target-controlled infusion: an assessment of pharmacodynamic target-controlled infusion of propofol and remifentanil using a response surface model of their combined effects on bispectral index discount silvitra 120mg free shipping impotence treatment drugs. The effects of fentanyl on sevoflurane requirements for loss of consciousness and skin incision generic silvitra 120 mg with amex diabetic erectile dysfunction pump. The effect of fentanyl on sevoflurane requirements for somatic and sympathetic responses to surgical incision silvitra 120mg low cost protein shake erectile dysfunction. Pharmacodynamics of alfentanil as a supplement to propofol or nitrous oxide for lower abdominal surgery in female patients buy generic silvitra 120 mg line erectile dysfunction medication reviews. The pharmacodynamic interaction of propofol and alfentanil during lower abdominal surgery in women. Efficient trial design for eliciting a pharmacokinetic-pharmacodynamic model-based response surface describing the interaction between two intravenous anesthetic drugs. An evaluation of remifentanil propofol response surfaces for loss of responsiveness, loss of response to surrogates of painful stimuli and laryngoscopy in patients undergoing elective surgery. An evaluation of remifentanil- sevoflurane response surface models in patients emerging from anesthesia: model improvement using effect-site sevoflurane concentrations. Response surface model predictions of emergence and response to pain in the recovery room: an evaluation of patients emerging from an isoflurane and fentanyl anesthetic. Introduction The heart is a phasic, variable speed, electrically self-activating muscular pump that provides its own blood supply. The two pair of atria and ventricles are elastic chambers arranged in series that supply equal amounts of blood to the pulmonary and systemic vasculature. Myocardium in the atria and 741 ventricles responds to stimulation rate and muscle stretch before (preload) and after (afterload) contraction begins. Coronary arterial blood vessels supply oxygen and metabolic substrates to the heart. The mechanical characteristics of the myocardium and its response to changes in autonomic nervous system activity allow the heart to adapt to rapidly changing physiologic conditions. The inherent contractile properties of the atria and ventricles and the ability of these chambers to adequately fill without excessive pressure are the major determinants of overall cardiac performance. As a result, abnormalities in either systolic or diastolic function may cause heart failure. Comprehensive knowledge of cardiac anatomy and physiology is essential for the practice of anesthesiology. This chapter describes the fundamentals of cardiac anatomy and physiology in adults. This foundation creates support for the valves and maintains the heart’s structural integrity as internal pressures vary. A small quantity of superficial subepicardial muscle also inserts into the cartilaginous skeleton, but most atrial and ventricular muscle directly arises from and inserts within adjacent surrounding myocardium. Myocardial fibers are continuously interwoven and cannot be separated into distinct “layers. The angle of the myocardial fibers changes within the ventricular wall’s thickness from the subendocardium to the subepicardium. In contrast to the2 subepicardial and subendocardial layers, midmyocardial fibers are arranged in a circumferential orientation and act almost exclusively to decrease chamber diameter during contraction. Valve Structure Two pairs of translucent, macroscopically avascular valves ensure unidirectional movement of blood through the normal heart. The valves open and close passively in response to pressure gradients produced during contraction and relaxation, respectively. The pulmonic valve leaflets are named for their anatomic locations (right, left, and anterior), whereas the aortic valve leaflets correspond to the adjacent coronary artery ostium if present (right, left, and non). The orifice areas of the pulmonic and aortic valves are nearly equal to the corresponding cross-sectional areas of their annuli during ejection. The sinuses of Valsalva are dilated segments of aortic root immediately superior to each aortic leaflet. Hydraulic flow vortices occur within the sinuses that prevent adherence of the valve leaflets to the aortic wall during ejection and facilitate valve closure by preserving leaflet mobility during diastole. These actions prevent the valve leaflets from4 inadvertently occluding the right and left coronary ostia. Despite the differences in their shapes, the anterior and posterior leaflets have similar cross-sectional areas because the posterior leaflet occupies a greater percentage of the annular circumference. Anterior-lateral and posterior-medial commissures connect the leaflets in these annular locations and are located above each corresponding papillary muscle. The chordae tendinae act as restricting cables to limit this superior motion of the mitral leaflets, facilitating their coaptation. Primary and secondary chordae tendinae attach to the leaflet edges and bodies, respectively, whereas tertiary chordae insert into the distal posterior leaflet or the myocardium immediately adjacent to the annulus. Papillary muscle contraction tensions the chordae, providing another mechanism by which the chordae prevent excessive leaflet motion. Tightening of the mitral annulus through a sphincter- like contraction of the surrounding subepicardium also aids in mitral valve closure. In addition to chordal rupture previously mentioned, papillary muscle ischemia or infarction may cause the mitral apparatus to fail, resulting in acute mitral regurgitation. This latter effect often becomes apparent during mitral valve replacement because many chordal attachments to the papillary muscles are intentionally severed. The tricuspid valve is normally composed of anterior, posterior, and septal leaflets. Notably, the proximal right coronary artery lies within this groove, and the vessel must be carefully avoided during tricuspid valve repair or replacement. A posterior view (right) shows left circumflex and posterior descending coronary arteries. Distal connections or collateral vessels between the major coronary arteries may also provide an alternative route of blood flow to regions of myocardium that lie distal to a severe stenosis or occlusion. Notably, the development of coronary collaterals in response to chronic myocardial ischemia is highly variable and quite unpredictable in patients with coronary artery disease. However, this is not always the case, as both vessels perfuse the posterior-medial papillary muscle in the remaining patients. Note that most left coronary flow occurs during diastole while right coronary flow (and coronary sinus flow) occurs mostly during late systole and early diastole. Except for the thin tissue layer on the endocardial surface of each chamber, the heart’s blood supply is derived almost entirely from perforating branches of the three major epicardial coronary arteries. The penetrating branches divide into dense capillary networks located parallel to the myocardial bundles. Arterial branches with diameters between 50 and 500 μm form interconnecting anastomoses (Fig. Coronary collaterals between different branches of the same coronary artery or between branches of two different coronary arteries are also variably present.

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The other important point to take into consideration is the pathology underlying the choice of the open abdomen management buy cheap silvitra erectile dysfunction doctor milwaukee. A different technique could be used in young trauma patients compared to septic elderly patients or to severe acute pancreatitis patients discount 120mg silvitra with mastercard erectile dysfunction treatment videos. In fact different pathophysiological mechanisms underlie these clinical conditions buy cheap silvitra 120mg online erectile dysfunction 19 year old male, and a different approach can be used buy silvitra 120 mg amex icd 9 code for erectile dysfunction due to diabetes. However a best device that can achieve a good fascial closure preserving the abdominal wall domain of the intra-abdominal organs is not found yet. They consist in closing the skin only by making the edges closer using towel clips (Fig. These techniques are cheap, immediately available, and easy to apply also for non-expert surgeons. Other problems are the impossibility to assess the intra-abdominal Towel clips Towel clips positioned to maintain the skin closed Alternatively a continue suture could be utilized Fig. As the abovemen- tioned techniques, the “Bogota bag” does not allow to remove intra-abdominal fuids and toxins and does not allow to reduce visceral edema [1, 4]. The non- application of a negative pressure could explain the low rate of enterocutaneous fstula reports (0–14. On the other hand, no retraction of the fascia is performed (defnitive fascial closure rates lower than 28%). They performed a small incision 1 cm away from the surgical incision margins, intravenous tubes were inserted through the incisions, and suction drains were inserted bilaterally near the skin margins above the internal sterile bag to remove fuids. The intravenous tubes are stretched every 24–36 h to re-approximated the abdominal wall. The nonabsorb- able meshes can be sutured at the fascia creating a tension-free closure and allow- ing a gradual re-approximation of the fascia when the mesh/sheet is plicated reducing the abdominal defect (Fig. At the re-exploration, the mesh/ sheet can be cut in the middle and after re-sutured approaching the two edges (also associated with a negative pressure therapy to increase the primary fascial closure rates) [2, 4]. The rates of primary closure ranged from 33 to 89% in case of use of nonabsorbable meshes. However, the authors report some bias due to the retrospective analysis and the indications for mesh implantation. The presence of porous in these meshes could be an advantage to facilitate the drain of intra-abdominal fuids. The risk of enteroatmospheric fstula, when the mesh is placed in contact with the bowel, is 5–10% for absorbable meshes. This mesh is cost-effective, feasible, and safe also in contaminated feld and helps the growth of granulation tissue [10]. Meshes can be also used to increase granulation tissue formation in patients in which skin closure is not possible, to allow the substrate for a skin graft later [1, 4, 5]. Zipper Zipper sutured to the fascial edges Zipper could be freely opened and closed to revise the abdominal cavity abdominal drainages could be placed Plastic sheet in direct contact with the abdominal content to protect the bowel Fig. At the abdominal re-exploration, the two sheets are overlapped in the middle of the opening abdomen allowing a gradual re-approximation every 24–48 h of the two edges (Fig. Recently a systematic review Mesh sutured to the Wittmann patch fascial edges over the plastic sheet. Velcro of the mesh permits to close the mesh and to maintain the tension and prevent the Plastic sheet over fascial retraction (at each the abdominal content revision the mesh (dark to protect the bowel blue) will be closed more tight to reduce the distance between the two fascial edges. Gauzes over Gauzes over the mesh (light the drainage blue) (green) Adhesive Drainages over plastic cover on the gauzes the top (light blue) Wittmann patch (2) Adhesive plastic cover on the top (grey) Platic sheet to protect the bowel (light blue) Drainage (to be Mesh (dark blue) connected to the aspiration) Fig. Literature reports no rates of incisional hernia in long-term follow-up with a low fstula rate of 0–4. A perforated plastic sheet covers the viscera; the sponge is placed above, between the fascial edges; the defect was covered by a Steri-Drape; and a suction drain connected to a pump is placed above the Steri-Drape. The negative pressure created by the pump reduces intra- abdominal fuids, keeps a tension on the abdominal wall and the fascia, and removes intra-abdominal cytokines [12]. The technique is a handmade negative pressure system and is realized putting a fenestrated, non-adherent sterile drape inside the abdomen to pro- tect viscera, covered by two surgical towels or gauzes. Above the gauzes two large silicone drains like Jackson–Pratt drain are positioning and covering by other two gauzes, fnally covering by a Steri-Drape over the wound to seal the abdominal cav- ity (Fig. Barker’s Vacuum pack Aspirative drainages between the 2 gauzes layers Adhesive plastic sheet over the superior gauze layer Plastic sheet in direct 2 gauzes layers, 1 over the contact with the abdominal plastic sheet and 1 over content to protect the the drainages bowel Fig. This system avoids bowel–ante- rior abdominal wall adhesions and makes an abdominal re-exploration easy, putting the fascia in tension. This layer is placed into abdominal cavity under the abdominal wall to protect the bowel, into the paracolic gutters and pelvis. The characteristic of the intra-abdominal drape is to remove all the perito- neal fuid. The polyurethane foam is placed between the two incisional margins and is then covered with a sterile adhesive drape. A small piece of the adhesive drape and underlying sponge are excised, and an interface pad with a tubing system is applied over this defect and connected to a pump and a canister to collect fuids. These devices are also easy for nursing and easy to change, reduce visceral edema, and maintain strength between the muscular edges [1, 2]. In these cases mortality was lower than 25% (par- ticularly in septic patients). This system approximates the wound and the muscle edges through dynamic trac- tion exerted by transfascial elastomers (Fig. The elastomers (a series of midline-crossing elastic bands) are inserted during the surgical procedure through the full thickness of the abdominal wall, in a perpendicular manner at a distance of approximately 5 cm from the medial fascial margin, and then are aligned about 3 cm apart across the defect and fxed to the so-called button anchors at the inser- tion site. A continuous dynamic traction is provided in a controlled manner between the elastomers and can be applied at the bed of patients avoiding a reintervention in the theater [20]. However, that system can be painful, can be uncomfortable, and can give unsightly scarring and ulcerations [19]. Atema in a systematic review [17] analyzing data from non-trauma patients reports an overall weighted rate of delayed fascial closure of 50. In trauma patients, literature reports ranges of fascial approximation from 68 to 88% after 3. However, some authors like Burlew [24] suggest that also in those patients, a sequential closure technique performed by a systematic protocol would achieve a higher rate (100% in her series) of primary fascial closure. The black sponges are affxed with an occlusive dressing, and standard suction with a com- mercial pump is applied [24]. Other authors like Fortelny [25] suggest the same approach in non-trauma patients showing a fascial closure of 78. The technique was performed using a dynamic fascial suture using vessel loop with vertical stitches at a distance of 1. Retention suture closure White sponge (Technique 1) above the plastic sheet covering the bowel. During the changing dress, the mesh was cut and sutured in tension to reduce the space between the two edges. It was necessary to defne a classifcation system to standardize clinical studies and to classify the pathol- ogy. Bjork and colleagues [27] proposed a classifcation, named Bjork’s classifca- tion divided in four grades.

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During insertion via a standard tracheal tube silvitra 120mg mastercard erectile dysfunction icd 0, each of the two distal ends is placed into a main stem bronchus cheap silvitra line erectile dysfunction medications cost. The selected lung is isolated by inflating the blocker’s balloon to the least volume necessary to occlude the main stem bronchus under bronchoscopic visualization best order silvitra erectile dysfunction medicine in ayurveda. This blocker should offer an advantage during bilateral procedures because each lung can be deflated without the need for repositioning the blocker order silvitra with visa impotence therapy. The characteristics94 of the various bronchial blockers are summarized in Table 38-3. Furthermore, unlike the other two groups, the majority of the Arndt patients required suction to achieve lung collapse. Once lung isolation was achieved, overall surgical exposure was rated excellent for the three groups. One minute longer to position a bronchial blocker or 6 minutes longer to collapse the lung with the bronchial blocker is insignificant when considering the duration of the thoracic procedure. The risk benefit and the patient safety of each individual patient should be considered when choosing the methods for lung isolation. They found no differences among the groups in the time taken to insert these lung isolation devices or in the quality of the lung collapse. The grading was done by the97 operating surgeons who were blinded as to which device was used. It is important, however, that the clinician does not limit his/her practice to the use of only one device but rather be versatile and comfortable in the use of several. The anesthesiologist should become familiar with the various devices used to achieve lung separation. Bronchial blockers can be safely and effectively used either for simple procedures such as a brief wedge resections or for more complexes extended procedure such as lobectomy or pneumonectomy. In these cases, when planning to provide lung separation, the postoperative period should be considered and the appropriate tube placed. Many procedures that are not considered to represent absolute indications for lung separation are lengthy and complex. Complex lung resection, with or without chest wall resection, thoracoabdominal esophagogastrectomy, thoracic aortic aneurysm resection with or without total circulatory arrest, or an extensive vertebral tumor resection, may result in facial edema, secretion, and hemoptysis, requiring postoperative ventilatory support. Other indications for postoperative ventilatory support are marginal respiratory reserve, unexpected blood loss or fluid shift, hypothermia, and inadequate reversal of residual neuromuscular blockade. In addition, it is more difficult to suction through the lumens, and a longer, narrower suction catheter is needed to reach the tip of the endobronchial lumen. Alternatively, the tube exchange may be performed under direct vision using one of several commercially available video laryngoscopes, such as the GlideScope (Verathon Medical), C-Mac (Karl Storz), or the Mc Grath (Aircraft Medical) (see Chapter 28). In addition, one should always plan in advance for the 2601 postoperative period when selecting the method of lung separation. Finally, in these cases, a close dialog with the surgical team is of vital importance. It is a common practice to visualize the tip of the blue bronchial cuff at the level of the carina to ensure that the left upper lobe orifice is not obstructed. High oxygen concentration serves to protect against hypoxemia during the procedure and provides a higher margin of safety. Some clinicians use an O 80%/N O 20% mixture as long that2 2 the SpO is maintained in a safe range. Tidal volumes (V ) ranging between 8 and 15T T mL/kg produced no significant effect on transpulmonary shunt or PaO. A V greater than 15 mL/kg may recruitT the atelectatic alveoli in the dependent lung. Retrospective clinical studies, however, suggest that the use of large V favors the development of lung injury in theseT patients. In this study, neither time course nor concentrations of2 pulmonary or systemic inflammatory mediators (cytokines) differed between the two ventilatory settings within 3 hours. In one study of patients undergoing pneumonectomy, 18% developed postoperative respiratory failure. The patients who developed respiratory failure had been ventilated with larger intraoperative V than those who did not (median, 8. In patients undergoing general anesthesia, lung recruitment maneuvers proved to be easy to perform and effective in reversing alveolar collapse, hypoxemia, and decreased compliance. The beneficial effect of an alveolar recruitment strategy on arterial oxygenation and respiratory compliance in anesthetized patients undergoing nonthoracic surgery in the supine position has been demonstrated by Tusman et al. It is important to apply the maneuvers over several minutes with a pressure of at least 20 cm H O and a peak of 40 cm H O. Because hypocarbia can only be achieved by hyperventilating the dependent lung, it raises the mean intra- alveolar pressure and therefore increases the vascular resistance in that lung. No severe adverse effects2 2 were reported in relation to the therapeutic hypercarbia. If this increase in resistance is limited to the dependent lung, blood flow can be diverted only to the nondependent (nonventilated) lung, increasing shunt fraction and further decreasing PaO2. Insufflation of oxygen without maintaining a positive pressure failed to improve PaO2. Intermittent reinflation of the collapsed (nondependent) lung with oxygen also resulted in a significant improvement in PaO. In addition, it is difficult to place the stapler on a lung that is not completely collapsed, and there is an increase in incidence of postoperative air leak. At this2 pressure, the lung becomes overdistended, which interferes with surgical exposure. The catheter to the nondependent lung is usually insufflated with 5 L/min of oxygen using a modified Ayre’s T- piece (pediatric) circuit, and the valve on the expiratory limb is adjusted to the desired pressure as read on the attached gauge. This is2 2 usually monitored indirectly with the use of a capnometer or other multigas analyzer. Frequent monitoring of arterial blood gases and use of a pulse oximeter continue throughout the operative period. It is also essential to work closely with the surgeon in case reinsufflation of the lung is necessary. Also, depending on the stage of surgical dissection, if a pneumonectomy is being performed, ligation of the pulmonary artery eliminates the shunt. A sudden increase in peak airway pressure may be secondary to tube dislocation because of surgical manipulation, resulting in impaired ventilation. In addition, the ability to auscultate by a stethoscope over the dependent lung is extremely important. If there is any doubt about the stability of the patient, or if the patient becomes hypotensive, dusky, or tachycardic, two-lung ventilation should be resumed until the problem has been resolved. Because of pericardial manipulation (during left thoracotomy in particular) and pulling on the great vessels, cardiac dysrhythmias and hypotension are not uncommon. Cardiotonic drugs should be prepared and kept available for use during any thoracic surgical procedure. They should be applied with a sustained peak pressure of 40 cm H O to be effective. Fluid administration during the2 procedure must be limited to avoid fluid overload that could increase pulmonary capillary permeability.

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Death by hyperventilation: a common and life- threatening problem during cardiopulmonary resuscitation buy silvitra on line amex erectile dysfunction vacuum pumps australia. Chest compression and ventilation during cardiopulmonary resuscitation: The effects of audible tone guidance purchase 120 mg silvitra amex erectile dysfunction nursing interventions. Delaying defibrillation to give basic cardiopulmonary resuscitation to patients with out-of-hospital ventricular fibrillation 120 mg silvitra impotence quotes the sun also rises. Automated external defibrillation versus manual defibrillation for prolonged ventricular fibrillation: lethal delays of chest compressions before and after countershocks discount silvitra 120mg amex erectile dysfunction beat filthy frank. Cardiocerebral resuscitation improves neurologically intact survival of patients with out-of-hospital cardiac arrest. Minimally interrupted cardiac resuscitation by emergency medical services for out-of-hospital cardiac arrest. Randomized clinical study of cardiopulmonary-cerebral resuscitation: Thiopental loading in comatose cardiac arrest survivors. Frequency and timing of nonconvulsive status epilepticus in comatose post-cardiac arrest subjects treated with hypothermia. Normoxic ventilation after cardiac arrest reduces oxidation of brain lipids and improves neurological outcome. Cardiopulmonary-cerebral resuscitation with 100% oxygen exacerbates neurological dysfunction following nine minutes of normothermic cardiac arrest in dogs. Normoxic ventilation during resuscitation and outcome from asphyxial cardiac arrest in rats. A randomized clinical study of a calcium-entry blocker (lidoflazine) in the treatment of comatose survivors of cardiac arrest. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. Treatment of comatose survivors of out-of- hospital cardiac arrest with induced hypothermia. Part 8: post-cardiac arrest care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. As a group, anesthesiologists are well prepared to assist their communities in planning for and in caring for patients who sustain injury or harm from such events. The former is important whether one lives alone; has a pet, family, or friends living with him or her, or has legal responsibility for a loved one (elderly parents, disabled person). Surgeons in the midst of a procedure should be contacted and urged to finish as soon as possible. Surgeons and anesthesiologists must consider what types of procedures can safely be undertaken and must prioritize care based on urgency and practicality. Category A are those weapons that are highly contagious, are associated with a high mortality rate, and have all the characteristics of a relatively ideal weapon of mass destruction. Therefore, as part of the containment process, to the extent possible, patients should be decontaminated at the site. Rather than guess whether radiation is still present it is best to disrobe patients and wash them with warm soapy water. Preparing to deliver care under austere circumstances, developing creative responses, and practicing (conducting simulations) regularly will mitigate the effects of a disaster and increase resilience for individuals, teams, and institutions. Introduction Hurricane Sandy, the Boston Marathon bombing, the Asiana plane crash, the pandemics caused by Ebola and Zika viruses are all events that entered our national consciousness, connoting vivid images of unfortunate circumstances. Although we cannot control, or even predict, the source of the next major disaster in the United States, it is far more likely to be Mother Nature and not an international terrorist who will be the force behind the destruction, but the latter scenario cannot be ignored. We can, however, control our preparedness and, therefore, our response to situations that result in mass casualties. As anesthesiologists, we have a responsibility not only to know our institution’s disaster plan and our role therein but also to prepare our family members and ourselves so that we do not become unintended victims of the next disaster, which in turn would result in our unavailability to provide care during a disaster and in our becoming an additional burden to the health-care system. Certainly, the size of the hospital has bearing on how one defines a given situation, as larger hospitals have more resources to manage a larger number of casualties without being overwhelmed. Nonetheless, environmental factors also play a role in how effectively a hospital can respond to a situation. For example, a hospital’s physical structure may be so damaged by an earthquake or a tornado that it is 4224 rendered inoperable, making it unsafe to provide care to its current patients, much less any new patients. As another example, flooding may result in the facility losing its external and its emergency back-up electrical power supply —making it, for all practical purposes, inoperable. Health disaster management: guidelines for evaluation and research in the Utstein style. Table 59-1 Types of Disasters According to the Joint Commission on Accreditation of Health-care Organizations 4226 The first step in any disaster response plan is to mitigate or reduce the risk. The 2015 Sendai Framework lays out a path for international collaboration on disaster risk reduction. The United States is also cognizant2 of the benefits to its foreign policy by assisting in humanitarian missions. Of significance is that it spends just as much to mitigate the effects of future catastrophes. Most residency program directors and anesthesiology residents would agree that although anesthesiologists are well prepared to manage individual patients, they lack the knowledge and education to manage the numbers of patients that might arise from a mass casualty event. There are entire books devoted to the topic and governments created large bureaucracies to address such events—so it would be naïve to think that a single book chapter could provide adequate knowledge to cope with all contingencies. However, there are certain principles that are common to all such events, independent of their etiology, and as a group anesthesiologists are as well prepared, if not better prepared, to assist their communities in planning for and in caring for patients affected by a disaster. We must expend the energy to be better educated, as the initial response to any disaster always occurs at the local level; therefore, as anesthesiologists we must be prepared to provide assistance during such emergencies. Although the clinical situations are not customary, these are services we provide on a daily basis to individual patients. However, disasters and mass casualty events are not something in which we participate on a daily basis; thus, education and training for these situations is critically important, beginning with preparation to respond to the most likely disasters that may occur in our respective geographic location. However, time and time again history demonstrates that enthusiasm for education is high after an event and then tapers off; maintaining that enthusiasm is difficult and therefore most, if not all, health-care facilities are not prepared to deal with mass casualty incidents, much less a mass casualty event, the exception being those facilities staffed by physicians with prior military training. Especially important for anesthesiologists who were deployed was the knowledge to repair and maintain anesthesia equipment, to perform peripheral nerve blocks using anatomic landmark techniques, to perform triage of mass casualties, and to treat patients with coexisting tropical disease. In dealing with acts of terrorism, geography is not helpful in anticipating what might occur, but that is not to say that one cannot anticipate what to expect. For example, a nerve agent, such as sarin, is most likely to be chosen as a chemical agent. Similarly, among biologic agents, anthrax, which was used in 2001, or smallpox would be the most likely choice because of the high lethality and infectivity associated with those two agents. However, to underscore what was stated here based on past experience, a natural or industrial event is more likely than a terrorist event. One must also be cognizant that although he or she might never plan to participate in a humanitarian mission overseas and therefore thinks that there is no need to train to work in an austere environment, the environment may become very austere depending on the circumstances of the disaster in which one finds oneself. This austerity might occur in a: • Mass casualty event in which the number of cases overwhelms capacity • Natural disaster in which the hospital is damaged or loses electricity or water • Disaster (natural/industrial/terrorist) in which care is provided on site. As described above, graduates of anesthesiology training programs in North America have the potential to cope well in such situations, provided that they understand the basic requisites of disaster management, the focus of this chapter.

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